ACES Policy and Procedure Review and Sessions Week 4—Blood, IV’s, and Blood Draws 1. Vascular Access and Maintenance - per IV Therapy 2. Continuous Administration of Fluids Through a Central Catheter 3. SASH Method for Flushing IV Lines 4. Central Line Maintenance and Care 5. Accessing an Implanted Port— IV Therapy and specially trained staff only 6. What’s Your Line Key Points 7. Blood Ordering Key Points 8. Blood Products Patient Information Form 9. Blood Product Administration/Summary Chart of Blood Products Administration: Leukopoor Blood, Packed Red Cells, Platelets or Fresh Frozen Plasma/ Adverse Reactions to Transfusions 10. Total Parenteral Nutrition (TPN) Administration 11. Dangers of D5W Article 11. Wound Care Braden Scale Information A.M. Session — Team Presentations (See Matrix): Peripheral and Central Lines / Blood draws TPN—Total Parenteral Nutrition Blood Administration Wound Care / Braden Scale IV Fluids/D5W Review P.M. Session GI Bleed Scenario Medical Scenario Trauma Scenario Quiz Evaluations
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WEEK 4 Fall 2009 SKILLS STATION MATRIX AND SIMULATION MATRIX Time
All Groups Together
0800-0830
Pretest/Personality Styles
0830-0900
IV Therapy Overview
0900-0930
Team Assignments/ Worksheets
0930—0945
Break TEAM Presentations
Group 1 0945-1015
Group 2 1015-1045
Group 3 1045-1115
Group 4 1115-1145
Group 5 1145-1215
Peripheral and Central Lines/ Blood draws
TPN
Blood Administration
Wound Care Braden Scale
IV Fluids
1215-1300
Lunch on your own
1315-1345
Group Scenario
Scenarios
GI Bleed
Trauma
Medical Patient
1345-1430
Group 1
Group 2
Group 3
1430-1515
Group 2
Group 3
Group 1
1515-1600
Group 3
Group 1
Group2
1600 –1620
Quiz
1620 –1630
Evaluations
Spring 2010
Vascular Access and Maintenance – Key Points per IV Therapy An IV site is the most important and most invasive medication delivery route for a patient. PLEASE take care of it! ASSESSMENT
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Always wash your hands before touching patient and when leaving the room. Observe IV site for redness or streaking up the vein as this is a sign of phlebitis. IV sites that exhibit redness, swelling, tenderness or drainage need to be changed. Check that dressing is clean, dry, and intact Observe entire length of IV tubing to check that Claves are attached, tubing is screwed on tight, or line is clamped where indicated. Ask the patient how the IV site feels.
ACCESSING LINES
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Always turn off IV infusions for 1 minute before doing blood draws. That way your lab results won’t be altered be what is infusing. Always turn IV infusions back on after completing tasks. Always swab off Clave with an alcohol wipe for 15 seconds and allow to dry before accessing or attaching IV tubing. If accessing a central line for blood draws, the line MUST be swabbed twice with an alcohol wipe for 15 sec and allowed to dry in between. This is especially important for blood cultures so the sample is not contaminated. Follow SASH policy for line flush – 2-3 ml of flush solution unless it is a midline or central line. If it is a PICC and you must flush more than 3 times per day use 10 unit/ml heparin. Peripheral locked lines are flushed with saline and locked with 3 ml of 10 unit heparin except 18g and 20g. These 18 and 20g peripheral lumens do well with only saline flushes. It is very important to use positive pressure and clamp during the last 0.5 ml to properly complete flush.
TROUBLESHOOTING /Frequently asking questions
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If the IV pump keeps alarming occlusion: Is the tubing kinked? LOOK at the entire length of tubing! Is the patient laying on the tubing? Is the tubing clamped? Is the drip chamber falling over and kinking the line? Is the pressure gauge set too low? Has the patient pulled on the tubing and kinked it at the catheter hub? Has the alarm been going off so long or so frequently that the line has been stagnant and plugged? Give it a flush!
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IV Therapy is often called to fix a line that is reported to have caused the pump to repeatedly alarm – only to find that the reason the pump is alarming is that the bag was empty or the medication dose was finished. Staff assumed it was the same problem again and did not assess the situation by: reading the alarm window or looking at the line each time. Call IV therapy to do dressing changes if the dressing looks soiled or wet. However, a small amount of blood under the dressing is OK especially if they are on heparin. The more we disturb the dressing the more the patient is going to bleed. If your patient is to take a shower, wrap the site with clear wrap and paper tape, then flush and lock the IV if possible. DO NOT pop the chamber open on the IV pump and leave the tubing attached without a flush and lock. When the tubing is pulled out it causes blood to back up into the line and the line to occlude.
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CENTRAL LINES /DIALYSIS CATHS
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ALWAYS USE A 10ml SYRINGE on ANY CENTRAL LINE. A syringe smaller than a 10 ml creates too much pressure inside the catheter which could cause the line to rupture, resulting in serious injury and even death to your patient. Many meds in the Acudose are not supplied in 10 ml syringes which means they must be transferred to a 10 ml syringe to administer through a central line / PICC. Example: the pain med syringes in the Accudose All central lines must have a filter and be on a pump. They also require a sterile transparent dressing. If a patient is admitted without a dressing please call IV therapy. The dressing is necessary to protect the patient from hospital germs. Central line dressings are done by IV therapy every seven days or as needed. If a dressing has loosened and the line is exposed that dressing needs a change. If the line is occluded try using a gentle pull to aspirate the occlusion. Aspirate several times to loosen the clot and pull it back into the syringe. Only after the clot is removed and syringe discarded should you attempt to gently push with a new flush. Do not force the flush as you may be releasing a deadly clot into the patient’s system. Always flush and positive pressure clamp all the lines on multi-lumen catheters (even when not in use). If a line has had TPN running and that lumen needs to be used for a blood draw, flush the lumen with 20 ml NS before drawing blood. (See protocol) After a blood draw, always flush line with 20 ml NS, then heparin if locking line, or connect to IV fluids. Blood draws should be done from the most distal lumen on a multi-lumen catheter. The lumens have small print on them identifying them as proximal, medial and distal. If the line is not marked it may be color coded with red for blood draws. Coagulation studies (i.e. INR, heparin assay, etc) cannot be drawn from central lines as those lines are maintained with heparin and could affect the results of the tests. No Dilantin/phenytoin sodium through a central line. However, fosphenytoin is not Dilantin and can be used in a central line. If a PICC line or tunneled groshong is damaged and you are unsure if it can be repaired, clamp the line in a manner that won’t damage the tubing and notify IV therapy ASAP
PORTS
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Only IV Therapy or specially trained staff can access (place the Huber needle through the skin into the port) ports. After the line has been accessed staff may utilize it to give fluids and meds etc. Any time a port is locked off 100 unit heparin is used.
DIALYSIS CATHETERS
• •
Dialysis patients usually have limited access for venipuncture. Fistulas tend to be placed in the non-dominant arm. IV sites are placed in the hands only on dialysis patients. Dialysis catheters are ONLY accessed with permission from the nephrologists. Even in the Emergency Department, permission must still be obtained before use. If obtained, IV therapy may then access catheter.
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ACES Policy and Procedure Review Key Points for Policy on: Continuous Administration of Fluids Through a Central Catheter (Groshong, Hickman, Subclavian, Jugular, PICC, Port-A-Cath, Femoral) For complete policy description, go to Policies and Procedures (IV Therapy) on Memorial’s Intranet.
Purpose: To administer continuous fluids, blood, and/or blood products as ordered by a physician. Key Points: •
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Prior to the administration of fluids through a central catheter the nurse will always check the physician order, gather primary I.V. tubing with a 0.2 Micron high pressure filter, infusion pump, wash hands, don non-sterile gloves, prime and date I.V. tubing for (72 hours). If a central line is going to be in place longer than 24 hours, be sure and place a primed luer lock extension on the central line before connecting the primed I.V. tubing to the catheter. After applying non sterile gloves, the nurse should clamp the central catheter and cleanse the catheter clave with an alcohol wipe for 30 seconds. Groshong and PICC catheter should not be clamped. Connect the primed I.V. tubing to the luer lock extension and open the clamps. Infusion pumps are mandatory for infusion of fluids through a central line catheter. Extensions and claves are changed at weekly dressing change by the I.V Therapy Nurse or sooner if: • Old blood present • Particulate matter present • Wear/tear on side port Document: 1. IV solution, 2. Flush solution or SASH, (if running I.V. and not compatible), on MAK and/or Electronic Medical Record
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IV Therapy
IV Therapy Continuous Administration of Fluids Through a Central Catheter (Groshong, Hickman, Subclavian, Jugular, PICC, Port-ACath, Femoral)
PURPOSE: To administer continuous fluids, blood, and/or blood products as ordered by a physician.
EQUIPMENT: 1. Prescribed solution 2. Appropriate tubing 3. Confirm appropriate filter selection with pharmacy. Filters are required to prevent air emboli or unresolved medication into circulatory system. 4. Tape 5. Infusion pump 6. Single luer lock ext. tubing with clamp or “y” extension 7. Non-sterile gloves 8. Alcohol wipes
PROCEDURE: 1. Wash hands. 2. Prime and date tubing. Be sure to place luer lock extension on all central lines if patient is expected to stay longer than 24 hours. 3. Wash hands and don non-sterile gloves. 4. Clamp catheter when indicated. Groshong central line and PICC Groshong catheters should not be clamped. 5. Cleanse catheter clave with alcohol wipe for 30 seconds. 6. Connect IV tubing using luer lock connection after ensuring air is not present in IV tubing line. 7. Open clamps if present. 8. Set infusion pump at prescribed rate. Pumps and filters are mandatory on all central lines. 9. To administer blood or blood products, follow Blood Procedure.
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10. When tubing is changed, the extension is not changed unless: A. Old blood present B. Particulate matter present C. Wear/tear on side port D. Extensions and claves are changed at time of weekly dressing change\ E. Tubing change every 96 hours or as required per solution administered i.e. TPN tubing is changed every 24 hours, etc. 11. Document flush solution/SASH or IV solution on MAK.
Effective Date: Prepared by:
07/31/1992
Approved by:
IV Therapy / Nurse Manager Policy & Procedure Committee
Date:
07/01/1992
Reviewd by:
Connie Conklin, RN Nurse Manager, Orthy/Neuro/IV Tx
Date:
Revised by:
Connie Conklin, RN Nurse Manager, Orthy/Neuro/IV Tx
Date:
Approved by:
IV Therapy / Nurse Manager Policy & Procedure Committee
Date:
12/12/1994, 12/10/2000 09/07/1992, 01/10/1998, 05/03/1998, 01/25/2004, 01/28/2009 01/28/2009
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ACES Policy and Procedure Review Key Points for Policy on: Central Line Care/Maintenance (Includes PICC) For complete policy description, go to Policies and Procedures (IV Therapy) on Memorial’s Intranet.
Purpose: Care and maintenance of central lines utilizing the least amount of manipulation of the line. EXIT SITE CARE, NEW CATHETER CARE Key Points: Dressing Change for an Inpatient Central Line Catheter • Prior to performing central catheter site care the nurse will gather a Central Line Dressing Tray, wash hands, don non-sterile gloves, and explain the procedure to the patient. Position the patient flat on back, remove the old dressing with non-sterile gloves toward the puncture site to prevent dislodging of the catheter. Document the entrance, exit, and tunnel sites and obtain cultures if there appears to be an infection; take patient temperature and notify physician. • Open the Central Line Dressing Tray, don with the sterile gloves and mask in the tray. Cleanse the catheter site in a circular motion moving outward making a 2” circle beginning first with alcohol wipe followed by 2% chlorhexidine; allow the alcohol and chlorhexidine to dry. Stabilize the central catheter and cleanse the catheter from exit site to hub with alcohol; apply the skin prep (packet) but do not allow the skin prep to come into contact with the exit site and catheter tubing. Always loop the catheter to the outside without touching the uncleansed area, allow the catheter loop to exit dressing on the side or bottom, cover the catheter site with a transparent or gauze dressing depending on site status. • A transparent dressing should cover the catheter hub up to but not on the extension of the central line catheter. Transparent dressings are replaced every 7 days and gauze dressings should be replaced every 24-48 hours; both dressing types should be replaced when damp, loosened, or soiled. • Change clave every 7 days by vigorously cleansing the hub of the catheter with alcohol for 30 seconds before replacing with new primed clave. Date dressing change and clave replacement and document. Drawing Blood from a Central Line Catheter Through a Clave With/Without Fluids Infusing Check physician orders, identify patient using two identifiers, explain procedure to patient, wash hands and don with non-sterile gloves before vigorously cleansing clave with alcohol for 30 seconds using two alcohol wipes. • Stop infusion of fluids for at least 1 minute before drawing blood specimens. If the central line catheter is locked, flush the central line catheter with a Luer-Lok syringe containing 10 ml of normal saline, then draw back 8 ml of blood into the same syringe, remove the syringe while maintaining positive pressure and discard. • Collect lab specimen with new syringe; remove the syringe while maintaining positive pressure, flush with two 10 ml(20 ml total) of normal saline using positive pressure to ensure that no blood remains in the side arm, line, or clave. If adding new clave—prime first. Follow with Heparin per protocol. •
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IV Therapy
IV Therapy Central Line Care / Maintenance (Includes PICC) PURPOSE: Care and maintenance of central lines utilizing the least amount of manipulation of the line. EXIT SITE CARE, NEW CATHETER CARE
EQUIPMENT: Central Line dressing tray: • 4x4s • Alcohol swab sticks and wipes • 2% chlorhexidine swab applicator • Sterile gauze or sterile transparent dressing • Tape • Mask • Gloves • Sterile gloves • Sterile drape • Skin Prep – from unit supplies
PROCEDURE: 1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12.
13.
Get supplies together. Check patient allergies. Wash hands with soap and water. Explain procedure to patient. Open kit; don sterile mask and gloves. With non-sterile gloves, remove old dressing. Dressing is always removed toward puncture site to prevent dislodging of catheter. Observe entrance, tunnel, and exit sites for redness, swelling, drainage, tenderness or warmth. If you think there is an infection, obtain cultures (see line culture procedure), finish changing the dressing, take patient’s temperature and notify physician. Remove gloves and wash hands again. Don sterile gloves. Cleanse skin around the catheter in a circular motion moving outward making a 2” circle. Beginning first with an alcohol swab stick followed by chlorhexidine. Allow the chlorhexidine to air dry. For maximum effectiveness, chlorhexidine needs to dry. Cleanse catheter from exit site to hub with alcohol wipe. Stabilize catheter during cleansing to prevent accidental removal. Apply skin prep as appropriate and allow to dry completely. If skin prep is not completely dry, skin will tear when dressing is removed. Also, do not allow skin prep to come into contact with exit site and catheter tubing. Loop the catheter to the outside without touching the uncleansed area. The loop protects from catheter dislodging. Allow the catheter to exit the dressing on the side, bottom, or top of dressing (depending on patient need), and cover with transparent or gauze dressing depending on patient’s status. Side or bottom exit of catheter prevents moisture (showers,
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14.
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emesis, etc.) from entering dressing. The transparent dressing should cover catheter hub up to, but not on, the extension. This holds catheter secure and does not allow it to stretch or break. • Outpatients - If a line will not be accessed between physician visits, a separate transparent dressing may be applied covering end cap. Dressings: • Transparent dressing: (dressing of choice) Place dressing adhesive side down and smooth over skin. Remove picture framing. Transparent is standard and is changed weekly and prn. • Gauze dressing: Lay gauze dressing over catheter, secure with tape on four sides. Gauze dressing may be used if excessive drainage is present – change every 48 hours. Dressing Change Schedule: A small amount of dried blood under the dressing is not an indication for changing the dressing. • Transparent: Once a week (7 days) or replace when damp, loosened, soiled, or when inspection of site is necessary. • Gauze: Once a day (24 hours) if purulent drainage exists at site, or when inspection of site is necessary. Q 48 hours if drainage is due to bleeding. Remove exit site sutures, including suture “wings” per physician order. If patient is neutropenic, consult oncology RNs prior to removing sutures. Keep sharp end of scissors away from catheter. Change clave every 7 days by removing existing clave, cleanse hub of catheter with alcohol wipes vigorously for 30 seconds and place new clave. Date dressing and clave.
LONG-TERM CATHETER CARE: ENTRANCE SITE CARE • Entrance site dressing: Remove dressing in 7 days. Replace dressing prior to 7 days if it becomes damp, loosened, or soiled.
EQUIPMENT: FLUSHING THE CATHETER • 10cc syringes (use nothing less than 10cc syringe) • Alcohol wipes (2) • Heparin, 10-100 unit per cc
PROCEDURE: 1. Wash hands. 2. Vigorously scrub clave (30 seconds) with alcohol wipes (15 seconds each). 3. Flush clave with 10cc normal saline pre-filled syringe, followed by Heparin 3-5ml • Rapid flushing (or push/pause method) is necessary to thoroughly clean the inside lumen. • When patient is discharged, instruct to use 3cc 100U Heparin for flushing unless condition warrants otherwise
IV BLOOD DRAWING THROUGH A CLAVE, CENTRAL LINE OR WITH A RUNNING IV: 1. Reminder do not draw coags through a central line that is maintained with heparin or if heparin drip is running. (See evidence below). If unable to obtain coag sample peripherally, notify physician. 1. IV extension should be in place if patient is hospitalized for 24 hours or longer.
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EQUIPMENT: • • • •
Four 10ml pre-filled normal saline syringes Heparin 10-100u/ml Alcohol wipes (2) Sterile clave if indicated
PROCEDURE: 1. Wash hands. 2. Preparing Equipment: • Prime new, sterile clave with NaCl. If new clave is indicated. 3. Wash hands and don gloves. 4. Running IV: • Stop infusion • Vigorously scrub port proximal to patient for 30 seconds using alcohol wipes (15 seconds each wipe) • Flush with 10ml NaCl. Draw back 8ml blood in syringe and discard. • Collect lab specimen with new syringe. • Flush with 10 ml normal saline and resume infusion. • During entire procedure ensure clave and syringe tip are not contaminated. 5. Locked line • Clean clave with alcohol wipes, 30 second vigorous scrub using 2 alcohol wipes (15 seconds each wipe). Flush line with 10ml NaCl, then draw back 8ml blood into same syringe and discard. (Flushing prior to procedure is optional) • Collect lab specimen with new syringe. Flush appropriately with normal saline. If any blood remains in line, flush with another 10ml normal saline. Ensure no blood remains in side arm, line or clave. 6. If unable to draw from line: • Try to reposition patient, i.e., raise arm on side of line, turn head to opposite side of line, cough or hold breath, lower and/or raise HOB if feasible. • If still unable to draw; then, ⇒ Locked Line: Remove syringe from clave; remove and dispose of clave, draw directly from hub. Place new clave after draw. ⇒ Running IV: Disconnect IV tubing from IV catheter hub, cap tubing to keep sterile, draw directly from hub and reconnect IV tubing after draw is complete. • If still unable to draw blood: ⇒ Locked Line: Apply new sterile, clave and flush with 10cc NaCl and 3cc 100U Heparin. ⇒ Running IV: Reattach IV tubing to extension hub and adjust flow rate as per previous order. ⇒ Then notify physician for discussion of options which may or may not include use of a declottting agent. Inability to withdraw from lines is not always an indication for the use of a declotting agent.
TROUBLE-SHOOTING CATHETER PROBLEMS: 1. Inability to flush, as evidenced by resistance felt when exerting gentle pressure on the plunger of a 10cc syringe or IV fluid will not infuse. • Check for clamps, kinks, or twists in line. • Consult an IV Therapist or another RN with IV expertise.
2. Leaking from catheter: • Turn off IV solution immediately. • If chemotherapy infusing, follow chemo spill procedure 4.18.3.
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Inspect lines for a tear, disconnection, or loose connection. If there is a tear, wrap area with sterile gauze, clamp line with smooth clamp between patient and tear (as close to tear as possible) to prevent blood loss or air embolus. Notify IV Therapy or Nursing Supervisor immediately. Line may occlude within 15 minutes. Often line can be repaired. Swelling around exit site: • Assess area for discoloration, crepitus (air), or fluid leaking from exit. • If extravasation of chemotherapy is suspected, stop infusion immediately and follow extravasation procedure 4.18.4. Swelling of neck and face: • Assess venous status from head, neck and affected arm, looking for distention of specific areas. • Assess Radiology report or Dept. for current CXR interpretation confirming line placement. • Notify physician (suggestion: 1) dye study to confirm line placement; 2) consider venous thrombosis). Air in IV line or extension: • Stop infusion. • Inspect all connections. • Using a 10cc syringe withdraw air from side port closest to air pocket. • If air pockets continue to form, change IV tubing and/or extension. Break in line at exit site: • Clamp line with smooth hemostat. • Cover with sterile gauze dressing and notify IV Therapist. • •
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EVIDENCE: "If any studies appear to be grossly inaccurate, redraw a blood sample from a peripheral vein (Almadrones, Godbold, Raaf, & Ennis, 1987; Mayo, Dimond, Kramer, & Horne, 1996; Winslow et al., 1995). • Blood coagulation studies should be drawn peripherally unless the catheter is maintained with normal saline because heparin adheres to the internal catheter lumen and will alter the coagulation results. At some institutions, coagulation levels are drawn after other blood samples are obtained or after discarding 10 mL of blood; however, the literature does not support this practice. • Some drugs (e.g., aminoglycosides, cyclosporine) can adhere to the catheter wall, which may obscure drug serum level testing (Huitemea, Holtkamp, Tibben, Rodenhuis, & Beijenen, 1999). Consider drawing these drug levels peripherally.
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Effective Date:
12/31/1994
Prepared by: Approved by:
Date:
Revised by:
Nursing Policy and Procedure Committee
Revised by:
Nursing Policy and Procedure Committee
Approved by:
Nursing Policy and Procedure Committee
Date: 05/03/1998, 09/07/2003, 11/18/2004, 06/08/2007 Date: 05/03/1998, 09/07/2003, 11/18/2004, 06/08/2007, 12/12/2008 Date: 05/03/1998, 09/07/2003, 11/18/2004, 06/08/2007, 12/12/2008
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ACES Policy and Procedure Review Key Points for Policy on: Accessing An Implanted Port - Regular or Power For complete policy description, go to Policies and Procedures (IV Therapy) on Memorial’s Intranet
Purpose: To gain access to an implanted port for infusion of IV fluids, medications or blood and blood products. May be located in chest, arms, or abdomen. *The Port-a-Cath will be accessed by RN’s with demonstrated competency only
Key Points: •
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Before accessing port: review the policy/procedure, check physician orders, gather equipment/supplies, explain procedure to patient, wash hands, position patient, verify with 3 identifiers to access and use power port for CT scans (power port purple wrist band, ID card or key chain card), apply patient mask. Don non sterile gloves and palpate the skin over the port and feel for septum, cleanse the skin with alcohol for 30 seconds and allow to air dry. May consider numbing the area as per physician order. Open sterile central line dressing tray, apply sterile mask, don with sterile gloves, aseptically prime the extension tubing and Huber needle with a 10 ml syringe of sterile saline, clamp extension tubing. Stabilize port and insert Huber needle at 90 degrees until it meets resistance, unclamp extension tubing, aspirate for blood return. If lab samples ordered, withdraw 8 ml of blood and discard, obtain lab samples then inject 20 ml of sterile normal saline, reclamp at the end of injection using positive pressure. Flush line with 5 ml of 100 units/ml of Heparin, reclamp at the end of injection using positive pressure. If Huber needle left in place for continuous or intermittent infusions, place sterile 2X2s under hub of Huber needle, apply skin prep and secure with steri-strips over needle keeping the needle perpendicular. Statlock and suture wing may be applied to further secure tubing, apply transparent dressing snugly leaving ends of extension tubing and clamp out of the dressings. Tape all junctions of tubing, tape circle of tubing with chevron to chest. If Power lac tubing and power port, remove sticker off package, attach to tubing to verify power access. Remove gloves and wash hands. Date and document. Change dressing every 5-7 days, date and document. Tubing change every 72 hours unless TPN, then change daily. Extension is not part of tubing and is not changed unless Huber needle changed.
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IV Therapy
IV Therapy Accessing An Implanted Port—Regular or Power PURPOSE: To gain access to an implanted port for infusion of IV fluids, medications or blood and blood products. May be located in chest, arms, or abdomen.
POLICY: The Port-a-Cath will be accessed by an RN with demonstrated competency in accessing ports.
EQUIPMENT: 1.
1 - 5 ml 100 unit/ml Heparin flush 2. Vial normal saline 20 ml or 2 single sterile field normal saline flushes 3. Central line dressing kit 4. 3 - 10 ml luer lock syringes - if blood draw 5. 2 - 10 ml syringes with 19 gauge needle for drawing up saline flushes from vial 6. Clave 7. Sterile towel 8. Alcohol wipes 9. Steri-strips 1/2 inch x 4 inch 10. Stat- lock and suture wing for hospitalization securement prn 11. Noncoring needle (Correct needle for respective port ie. miniloc, power loc, etc.) IV Ther apy has 20g noncoring in 1/2", 3/4", 1", 1 1/4" and 1 1/2". Power locs is 3/4" and 1 and 1 1/2" 20 g. Preferred numbing agent. Before You Start the Procedure do the following:: 1. Have an assistant available. 2. Place everything in the room and make space to work from near the head of the bed. 3. Check allergies. Ask what type of port and verify.
1. 2. 3. 4.
POINT OF EMPHASIS: The entire procedure shall be done under sterile conditions. Assistant will assist with filling syringe with NS so syringe remains sterile. For children, Emla cream may be applied 1 - 2 hours before accessing to numb the area and this requires a physician order. For adults, Ethyl Chloride spray may be used or Xylocaine.
PROCEDURE: 1. 2.
Place patient in comfortable position. Palpate port site to locate septum. Note shape of port to determine type of port. Triangular shape indicates power port. Also note bumps on septum that also indicate power port.
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3.
If accessing power port, also verify that patient has power port purple wrist band, ID card or key chain card. If none present check chart records, 3 identifiers are needed to be able to access and use power port for CT scans. 4. Explain procedure to patient and apply patient mask. 5. Wash hands. 6. Open sterile dressing tray kit and apply mask. 7. Put on sterile gloves. 8. Use Chlorahexadine swab to clean site and let dry. 9. Attach non-coring needle to clave. Flush air from tubing, clamp extension. Grippers come attached to non-coring extension tubing. 10. Apply patient preferred numbing agent at this time 11. Locate and stabilize port with 3 fingers of one hand. 12. Grasp huber needle with attachments in other hand, place needle perpendicular to port and enter skin at the chosen site within center of port with the hub in the direction you wish it to be left. Press firmly, keeping huber needle straight, until metal tip touches metal backing on port. 13. Open clamp, slowly pull back on syringe until you see blood to make sure you have accessed the port septum. Blood should return easily. Withdraw 6 ml of blood and discard in order to clear heparin from the port. If needed, obtain lab samples now. They inject the 20 ml normal saline slowly - reclamp at the end of injection using positive pressure technique. 14. Place folded 2x2 under hub of huber needled prn to level. Apply skin prep on skin where strips will be. Secure well with steri-strips over needle keeping needle perpendicular. Statlock and suture wing may be applied to tubing to further secure tubing. 15. Apply occlusive/transparent dressing snugly over entire site leaving ends of extension tub ing and clamp out of the dressings. 16. Wipe clave with alcohol wipe for 15 seconds and let dry. Do this twice prior to flushing with 5 ml of 100 unit Heparin using positive pressure. Be sure extension tubing is clamped before removing syringe. 17. Remove gloves, tape all junctions of tubings, tape circle of tubing with chevron to chest so no pulling or stress is on the noncoring needle. •IMPORTANT: If this is Power loc tubing and power port take sticker off of package and attach to tubing so that Cat Scan and staff will know this is a verified power access. 18. Change dressing every 5 -7 days. 19. Reaccess every 5 - 7 days. 20. Document dressing date, length of needle and initials. Also chart on parenteral fluids sheet/ chart. 21. If port is accessed with no blood return, talk with floor RN or Physician as soon as possible. about verifying port function with either dye study or TPA.
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Effective Date: Prepared by: Approved by:
02/28/1988 Nursing Policy and Procedure Committee
Date: 02/01/1988, 10/17/2008
Reviewd by:
Nursing Policy and Procedure Committee
Date: 12/12/1994, 12/10/2000, 01/25/2004, 12/20/2007, 10/17/2008
Revised by:
Nursing Policy and Procedure Committee
Date: 01/15/1991, 01/25/1998, 06/06/2007, 12/20/2007, 10/17/2008
Approved by:
Nursing Policy and Procedure CommitteeI
Date: 01/15/1991, 01/25/1998, 06/06/2007, 12/20/2007, 10/17/2008
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IV Therapy
IV Therapy Guidelines for IV Catheter Maintenance POINT OF EMPHASIS: A. Use a 10 ml or larger syringe and flush vigorously but do not force. Maintain positive pressure. B. Types of Central Lines – all are to be maintained with heparin/saline using SASH method. • Groshong – blue catheter – PICC (peripherally inserted central catheter) • Power PICCs - purple catheter • Hickman or Broviac – white catheter – chest • Subclavian, Jugular, Femoral • Per-Q-Cath – white catheter – PICC • V-Cath – white catheter - PICC • Port-A-Cath –port implanted under skin A. LINE MAINTENANCE • Broviac i. Adult / Child ♦ 5 ml 100 units Heparin every 7 days or after each use ♦ If 3 or more flushes are needed per day and/or patient’s platelet count is < 30,000, use 5 ml 10 unit/ml Heparin ii. Infant ♦ 2ml 10unit/ml Heparin every 12 • PICC i. Adult / Child ♦ As with Broviac ii. Infant ♦ 3 ml 10 unit/ml Heparin every 8 hours or with each medication • Peripheral Lines – Routine i. Medications ♦ 5 ml NaCl before and after each medication (SASH method) ii. Maintaining a locked line: ♦ Adult ⇒ 5 ml NaCl every12 hours or after each use. Exception: Patients with 22g and smaller (SASH method) ♦ Peds ⇒ 5 ml 10u Heparin Q 12 Hours or after each use. • Midlines – 8 inches long – peripheral i. Groshong ♦ blue catheter ii. Per-Q-Cath ♦ white catheter iii. Intracath ♦ green catheter iv. Medications ♦ 5 ml NaCl before and after each medication, then follow maintenance procedure below.
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v. Maintaining a locked line—Adult/Child ♦ 5 ml 10 units Heparin every 12 hours or after each use. Port-A-Cath – Implanted port i. Reassess accessed port every 7 days (Peds may be exception) ii. Maintaining a de-accessed port – 5ml 100units/ml Heparin every 30 days
Effective Date: 02/28/1999
Prepared by:
Julia Patten
Approved by:
IV Therapy / Nurse Manager Policy & Procedure Committee
Date:
02/01/1999
Reviewd by:
Connie Conklin, RN Nurse, Ortho/Neuro/IV Tx
Date:
01/10/2000, 12/12/2003, 12/20/2007
Revised by:
Connie Conklin, RN Nurse, Ortho/Neuro/IV Tx
Date:
01/10/2000, 12/12/2003, 12/20/2007
Approved by:
IV Therapy / Nurse Manager Policy & Procedure Committee
Date:
01/10/2000, 12/12/2003, 12/20/2007
Spring 2010
01/31/2003 Prepared by: Approved by:
Nursing Policy and Procedure Committee
Reviewd by:
Nursing Policy and Procedure Committee
Revised by:
Nursing Policy and Procedure Committee
Approved by:
Nursing Policy and Procedure Committee
Date: 01/02/2003, 10/06/2008 Date: 08/27/2003, 10/06/2008 Date: 11/18/2004, 08/29/2008, 10/06/2008 Date: 11/18/2004, 08/29/2008, 10/06/2008
Spring 2010
Key Points: For Ordering Blood Products Clarification of terms utilized on blood order slips: Blood Type: patient is drawn and sample evaluated to determine patient blood type (i.e. A, B, O, +, -) Band and Hold: patient is drawn and blood band placed on patient; patient blood sample is placed in fridge (on hold) Type and Screen: patient is drawn and blood band placed on patient; blood type and antibody screen is performed on sample but there is NO crossmatched blood available. If antibody screen is positive or there is anything to cause the blood bank to be concerned, the floor is notified by the Blood Bank to request a crossmatch order from the physician. A Type and Screen can be converted to a crossmatch in a short amount of time in emergency cases without a redraw. Type and Crossmatch: patient is drawn and blood band placed on patient; antibodies are tested and crossmatched. Blood bank completes the processing of the blood and places a certain number of units (as determined by the physician—i.e 4 units on hand, 2 units on hand, etc) in the Blood Bank fridge for that patient. NOTE: • Anything in red on the blood order slip requires the patient to have a blood band on their body (arm) not on the bed!
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Anything in white on the order slip does not require a blood band on the patient
Key points: Completion of the Blood Transfusion Record Section I - PRE-TRANSFUSION: •
All blood products require a physician order and patient consent.
•
Physicians should be informing patients of need for transfusion, risks/benefits.
•
Nurses reinforce physician recommendation by answering questions and providing a Patient Education sheet/form for Blood and /or Blood Products. This form reviews common questions and answers involving blood administration. It is form # 0180 - found in the Memorial Forms Catalog, and is provided to patients prior to their blood transfusion.
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Following receipt of patient education, the patient signs the consent to transfusion in Section I if able and not previously signed.
3. Staff must compare patient ID band with Name and Medical Record number on Transfusion Record 4. Staff must verify patient’s Crossmatch Armband # - document this number on the Transfusion Record 5. Staff must verify/compare with the Transfusion Record the following: • Unit #, • Expiration date of blood component • Blood type and Rh Staff performing the mandatory double check sign in Section 1—one of which MUST be the person administering the component.
Spring 2010
Spring 2010
General Nursing Policy and Procedure Manual
General Blood/Blood Products Administration and Transfusion Reaction PURPOSE: To safely administer whole blood, leukopoor blood, packed red blood cells, platelets or fresh frozen plasma.
EQUIPMENT: • • • • • •
250 ml or 500 ml bag of normal saline “Y” type blood administration tubing or appropriate pump tubing with standard blood filter (170 microns) When possible use a 20 gauge IV catheter or larger for IV site Product to be infused Infusion pump Current cross match band ( If it is necessary to remove the patient’s current cross match band, it must be replaced immediately by calling Lab.)
PROCEDURE: 1. Physician order required Verify physician order for blood product 2. Answer patient questions and provide education—Blood Product Transfusion Patient Education Form available in Memorial Forms Catalog 3. Setup for IV tubing. Multiple units may be infused through the same tubing. • Make sure all clamps are closed. • Insert one spike connecter from Y blood set into normal saline. • Open clamp to saline . • Prime line with normal saline and start saline. • Tubing must be changed at least every 4 hours, regardless of how many units of product have been transfused. • Tubing must be changed every time a different blood product is hung 3. Connect blood tubing at closest port to the patient. Blood should not be infused through a needle in a click lock fashion due to cell damage. 4. Observe IV site for signs of swelling, redness, hematoma or induration. 5. Request blood product from the blood bank. Once product arrives, inspect for the following: • Excessive air bubbles • Purplish/brown hue • Clots • Puncture in the bag • If problems with unit or unable to administer unit– return to Blood Bank with in 20 minutes 6. Obtain patient consent and record on pre-transfusion Section of YVMH Transfusion Record which arrives with the blood component 7. Perform and record baseline vital signs on the blood transfusion record.
Spring 2010
8.
Prior to starting transfusion, mandatory double check ) by RN/RN, RN/LPN II, or RN/MD must occur (one of the persons checking MUST be the person administering the blood component). Checks to be included are: • Patient's name • Medical record number • Cross match number - found on yellow sticker (3 letters and 4 numbers) • Expiration date of unit • Blood type and Rh • Unit number • Compatibility • If any discrepancies found while double checking send product back to the lab immediately 8. Hang the product: • Insert the remaining spike connector of the Y tubing into the blood product. • Close clamp to saline and open clamp to the blood product. • Prime the tubing to the point of IV entry of the patient. For the initial 15 minutes the rate should be less than or equal to 120ml/hour. During this time watch for a blood transfusion reaction. (See end of policy for signs/symptoms of reaction) 9. At 15 minutes take vital signs and document on the blood transfusion record. Question the patient for signs/symptoms of reaction. If no signs/symptoms of reaction present, increase the rate of transfusion to 120ml- 300ml/hr or per doctor orders. 10. Follow doctor's orders for rate of transfusion. Usually RBC’s in 1-2 hours and Plasma in 20-30 minutes. All blood products must be transfused within 4 hours of hang time. 11. Clear tubing between units with Normal Saline. This gives an opportunity to assess patency of blood filter, clears first unit of blood from tubing and helps to identify the unit responsible for a possible reaction. 12. Immediately upon completion of each product transfused, record a final set of vital signs and document on the transfusion record. Dispose of the empty blood bags and IV tubing. 13. Return the transfusion record to the patient’s chart. NOTE: Only saline should be infused with blood. • No IV medications should be infused in the blood tubing. If need to give other IV medications, stop blood, flush with normal saline at port closest to patient, administer medication, flush with normal saline, restart blood. POSSIBLE TRANSFUSION REACTION A. If there is a reason to be suspicious of a reaction, vital signs can be checked any number of times. Initiate the following: 1. Stop infusion but do not disconnect pending doctor’s orders 2. Keep IV site open and flush with 10ml normal saline at port closest to the IV site 3. Obtain Vital signs 4. Contact physician 5. Notify the lab (they may want you to return unit to lab) B. If reaction not confirmed continue transfusion at physician’s discretion C. If reaction is confirmed (by physician /blood bank /pathologist) 1. Complete “Reaction” portion of Transfusion Record and chart in Nurse’s Notes all pertinent information. 2. Send Transfusion Record and if indicated the first urine specimen to the lab. Keep a copy of the Transfusion Record for the patient’s chart. 3. Lab may request sending of remaining blood and tubing to them. C. Transfusion reactions fall in the following categories: • ALLERGIC: Usually mild: itching, urticaria, asthma; rarely anaphylactic. • FEBRILE: Shaking chills, fever, headache, nausea; less commonly, hypotension. • HEMOLYTIC: Similar to febrile reactions with additional symptomatology: apprehension, chest pain, shock, hemoglobinuria, abnormal oozing of blood, back pain.
Spring 2010
CIRCULATORY OVERLOAD: Cough, shortness of breath, neck vein dilation, pulmonary congestion and edema. • HYPOTHERMIC: Cardiac arrhythmias and cardiac arrest (extreme reaction to large amounts of cold blood). • DISEASE TRANSMISSION: Hepatitis, malaria, HIV, syphilis, HTLV-I, cytomegalovirus (CMV), Graft-vs-Host. • TRANSFUSION-RELATED ACUTE LUNG INJURY (TRALI): Respiratory distress, non-cardiogenic pulmonary edema, and severe hypoxemia. • POST-TRANSFUSION PURPURA: Sepsis, severe rigors (especially if accompanied by cardiovascular collapse), increased temperature of greater than or equal to 40oC, shock. Patients should be educated on symptoms of: • Delayed Transfusion Reaction –which can occur up to 2 weeks post transfusion Fever, with or without chills ; shaking chills ; pain at infusion site; pain in chest, abdomen, back , flanks; blood pressure changes; respiratory distress; hives, rash, redness or itching; nausea with or without vomiting; blood in urine; unusual bleeding tendencies; jaundice or yellowing of the skin and eyes •
FOR ADDITIONAL INFORMATION, SEE TABLES BELOW : • blood transfusion • transfusion reaction • blood administration
Spring 2010
BLOOD TRANSFUSION REACTION TABLE CATEGORY
SYMPTOMS
TREATMENT
PREVENTION
Allergic Reactions (patients with history of allergies)
Urticaria, itching, asthma: rarely, anaphylaxis (1gA deficient patient)
Antihistamine PO or IM; epinephrine for acute asthma
If clerical checks are negative, medicate and continue transfusion. Patient may be pre-medicated or given washed red cells for future transfusions. Use 1gA deficient plasma for patients having anaphylaxis.
Febrile Reactions (patients with history of multiple transfusions or pregnancies)
Shaking chills, fever, headache, nausea, non-productive cough; less frequent are hypotension, chest pain, vomiting and dyspnea.
Acetaminophen or aspirin
Pre-medicate or give leukocyte-reduced products (use of leukocyte removal filters)
Hemolytic Reactions
Shaking chills, fever, hypotension, apprehension, headache, chest pain, shock, nausea, vomiting, dyspnea, flushing, abnormal oozing from cut or surfaces, hemoglobinuria, back pain, pain at infusion site, anuria
Treat hypotension and promote renal blood flow to maintain urine output at 100mL/hour (80-120 mg of intravenous furosemide)
Careful adherence to procedures at every step in the transfusion process from sample procurement to infusion of unit. Accurate recordkeeping of patient transfusion history (especially clinically significant antibodies)
Circulatory Overload (Patients with compromised pulmonary or cardiac status)
Cough, shortness of breath, neck vein dilation, pulmonary congestion and edema, congestive heart failure, cyanosis, rapid increase in systolic blood pressure.
STOP Infusion: put patient in sitting position; administer diuretics and oxygen.
Give red cells, not whole blood. Administer slowly. Unit may be allocated and given in portions. Premedicate with diuretics.
Hypothermic Reactions
Cardiac arrhythmias, cardiac arrest
Use blood warmer, call physician, administer CPR, warm the patient
Warming blood – CAUTION: use warmer with alarm. Do not warm blood over 42ºC. Keep the patient warm. Contact House Supervisor to obtain warmer and appropriate tubing.
Disease Transmission
Hepatitis, malaria, HIV, CMV, Graft-vs-Host (GHV, onset up to six months post-transfusion), syphilis,
As appropriate for diagnosis
Careful screening and testing of donors. Prompt reporting of every possible transfusion-associated
Spring 2010
CATEGORY
SYMPTOMS
TREATMENT
PREVENTION
Disease Transmission (Continued)
HTLV-I, Yersinia enterocolitica.
As appropriate for diagnosis
hepatitis or AIDS case. Irradiation of products containing while blood cells for patients at risk of GVH. Use of leukoreduced or CMV negative products is recommended for persons at risk for CMV infections.
Transfusion-Relate Acute Lung Injury (TRALI)
Acute respiratory distress, severe bilateral pulmonary edema and severe hypoxemia (arterial oxygen tension commonly of 30-50 mmHg) associated with fever. Patient may have hypotension which is unresponsive to fluid administration. Symptoms occur within two to six hours of recent transfusion.
Rule out cardiogenic causes. Prompt and igorous respiratory support (oxygenation and/or mechanical ventilatory assistance are frequently needed).
Often caused by donor antibodies to HLA antigens or donor leutoaggultinins. May be recipient antibody induced (to donor WBC antigen), or may be due ot other conditions causing complement activation (older blood components). Leukoreduced products may help prevent future reactions in approximately 10% of cases.
Post-Transfusion Purpura
Bleeding or hemorrhagic symptoms five to ten days post-transfusion, hematuria, melena, markedly decreased platelet count.
High dose IVIG. Plasmapheresis may be effective. Request screening for platelet specific antibodies.
For future transfusions, use washed platelet products or deglycerolized red cells (both special orders) or avoid platelet antigen responsible (e.g., PLA1 [HPA-la]negative products for patient with anit-PLA1).
Spring 2010
Summary Chart of Blood Components and average volumes of each product. Component and Rate of Administration
Major Indications
Not Indicated For
Special Precautions Crossmatch Needed
Hazards (see IV Guidelines: Adverse Reactions to Transfusions)
Red Blood Cells, Washed or Deglycerolized (no standard for leukocyte removal) Available only by special order 200 - 300 ml
Where 90% or See Red Blood Cells greater removal of plasma is indicated (severe allergic reactions; unusual IgA phenotype). Frozen/deglycerolized red cells may need to be used for rare blood types
Yes
See Red Blood Cells; hemolysis due to incomplete deglycerolization can occur
Red Blood Cells, Leukocytes Reduced 325 - 410 ml
Symptomatic anemia, febrile reactions from leukocyte antibodies, CMV-safe, reduced incidence of HLA allo-immunization
See Red Blood Cells; Leukocyte reduction should not be used to prevent GVHD
Yes
See Red Blood Cells; if using bedside leukocyte reduction filter, hypotensive reaction may occur
Whole Blood Autologous only
Symptomatic anemia with large volume deficit
Condition responsive to specific component; see Red Blood Cells
Deficit of labile and stable plasma coagulation factors and TTP
Condition responsive to volume replacement; coagulopathy that can be more effectively treated with specific therapy
530 - 625 ml
Frozen Plasma, Cryoreduced Plasma Flow rate 5-10 mL/min 180 - 330 ml
Must be ABOSee Red Blood Cells; identical; labile circulatory overload coagulation factors deteriorate within 24 hours after collection No
Infectious diseases; allergic reactions; circulatory overload
Frequent repeat doses may be necessary No Crossmatch needed
Infectious diseases; allergic reactions
No
Infectious diseases; septic/toxic, allergic, febrile reactions, GVHD
Cryoprecipitated AHF 10 - 15 ml/bag
Hypofibrinogenemia, Conditions not Factor XIII deficiency, deficient in contained factors Hemophilia when factor concentrates not available
Plateletpheresis ("Platelets, Pheresis" Single Donor Platelets, HLAMatched, or Leukoreduced Plateletpheresis 5-10 mL/minute 250 - 400 ml
Bleeding from thrombocytopenia or platelet function abnormality; Prevention of bleeding from marrow hypoplasia
Plasma coagulation deficits and some conditions with rapid platelet destruction (e.g., TTP) unless life threatening hemorrhage
Granulocytes Special Orders 300 - 400 ml volume
Neutropenia with infection, unresponsive to appropriate antibiotics
Infectious diseases; Infections responsive Must be ABOallergic, febrile to antibiotics, compatible. Use reactions, GVHD eventual marrow standard filters. recovery not Should not use some expected filters (check manufacturer's instructions)
Spring 2010
SOURCE: Technical Manual, AABB, 15th edition, 2005 Standards for Blood Banks and Transfusion Services, AABB, 23rd edition, 2004 Circular of Information for the Use of Human Blood and Blood Components
KEY WORDS:
Effective Date:
02/15/2008
Prepared by:
Tammy Smeback/Nurse Manager/Memorial Hospital
Approved by:
Nursing Policy and Procedures Committee
Date: 03/12/2008
Reviewd by:
Nursing Policy and Procedures Committee
Date: 03/12/2008, 11/21/2008
Revised by: Approved by:
Date: Nursing Policy and Procedures Committee
Date: 03/12/2008, 11/21/2008
Spring 2010
ACES Policy and Procedure Review Key Points for Policy on: Placement of Patients R/T Medication and Treatments For complete policy description, go to Policies and Procedures (Medications) on Memorial’s Intranet
Purpose: All patients receiving the following treatments shall be Assessed and Reassessed at the level of a CCU patient. Key Points: •
•
• •
All patients receiving cardiotonic drugs: See policy for list of medications. Any pressor agents should be administered via a central line when possible. Any patient receiving dopamine or dobutamine requiring titration with frequent vital signs will be transferred to CCU. All patients receiving the following interventions &/or treatments: • Intubated and on the ventilator • Medically unstable suicidal patient • Pulmonary Artery Monitoring • ICP Monitoring • Hyperthermic or Hypothermic therapy All adult patients on the Diabetic Ketoacidosis Protocol with an Insulin drip infusion. All patients receiving selected intravenous infusions of anxiolytics, antipsychotics, and anesthesia adjuncts. See policy for list of medications.
Spring 2010
Medication Management Medication Placement of Patients With Medications or Treatments Requiring Cardiac Monitoring POLICY: All patients receiving the following treatment shall be placed on a cardiac monitor and cared for by appropriately trained staff. PURPOSE: To ensure adequate cardiac monitoring of patients receiving the following treatment. Amiodarone drip Diltiazem drip Lidocaine drip Esmolol Labetolol drip - except when used in Labor and Delivery to treat PIH (pregnacy induced hypertension) or HELLP (hemolysis elevated liver enzyme levels and low platelet count) 6. Other IV Beta Blockers for acute rate or blood pressure control 7. Nitroglycerin drip without titration 8. Cooling Blanket 9. Abcximab (Reopro) 10. Tirofiban (Aggrastat) 11. Epifibitide (Integrilin) 12. Furosemide drip or Bumetanide drip 1. 2. 3. 4. 5.
Effective Date:
01/05/2000
Prepared by:
Lynda Boggess/CCU NSO/Memorial
Approved by:
Nursing Policy and Procedure Committee
Date:
Reviewd by:
P&T Committee
Date:
Revised by:
Nursing Policy and Procedure Committee
Date:
Approved by:
P&T Committee
Date:
01/05/2000, 07/17/2008 07/17/2008, 01/15/2009, 01/13/2010 11/11/2003, 12/22/2006, 07/17/2008 11/11/2003, 12/22/2006, 07/17/2008, 01/15/2009, 01/13/2010
Spring 2010
Medication Management Medication Placement of Patients Receiving Medications or Treatments Requiring Critical Care Monitoring
POLICY: All patients receiving the following treatments shall be Assessed and Reassessed at the level of a Critical Care Unit patient.
PURPOSE: To ensure adequate monitoring of patients receiving the following Treatment. 1. Intubation – on ventilator 2. Patient at risk 3. Suicide attempt- (medically unstable). Medically stable patients will be admitted to Inpatient Psychiatry. 4. Pulmonary Artery(PA) line monitoring 5. Intracranial Pressure (ICP) monitoring 6. Receiving Hyperthermia or Hypothermia Therapy 7. Patient receiving the following cardiotonic drugs: Dopamine >5mcg/kg/min or requiring titration* Nitroglycerine drip *Requiring Titration Dobutamine – requiring titration*. Epinephrine Norepinephrine (Levofed) Nitroprusside Phenylephrine (Neosynephrine) PropofolI. Vasopressin drip Any paralytics Lorazepam drip (Ativan) Midazolam drip (Versed) Haloperidol (doses>10mg/hr) Thrombolytic agents for MI, 8. Stroke,
9. PE 10.Insulin drip - Adult patients on the Diabetic Ketoacidosis Protocol with the exception of pregnant patients being managed on the Family Birthplace.
*Any pressors should be run via a central line when at all possible. *Patient may remain on a medical/surgical unit or ACU (as per physician order) while receiving Dopamine at
